Abdominal pain

Last updated

Abdominal pain
Other namesStomach ache, tummy ache, belly ache, belly pain, gastralgia
Gray1220.png
Abdominal pain can be characterized by the region it affects.
Specialty Gastroenterology, general surgery
CausesSerious: Appendicitis, perforated stomach ulcer, pancreatitis, ruptured diverticulitis, ovarian torsion, volvulus, ruptured aortic aneurysm, lacerated spleen or liver, ischemic colitis, ischaemic myocardial conditions [1]
Common: Gastroenteritis, irritable bowel syndrome [2]

Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important. [3]

Contents

Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. [2] About 15% of people have a more serious underlying condition such as appendicitis, leaking or ruptured abdominal aortic aneurysm, diverticulitis, or ectopic pregnancy. [2] In a third of cases, the exact cause is unclear. [2]

Signs and symptoms

The onset of abdominal pain can be abrupt, quick, or gradual. Sudden onset pain happens in a split second. Rapidly onset pain starts mild and gets worse over the next few minutes. Pain that gradually intensifies only after several hours or even days has passed is referred to as gradual onset pain. [4]

One can describe abdominal pain as either continuous or sporadic and as cramping, dull, or aching. The characteristic of cramping abdominal pain is that it comes in brief waves, builds to a peak, and then abruptly stops for a period during which there is no more pain. The pain flares up and off periodically. The most common cause of persistent dull or aching abdominal pain is edema or distention of the wall of a hollow viscus. A dull or aching pain may also be felt due to a stretch in the liver and spleen capsules. [4]

Causes

The most frequent reasons for abdominal pain are gastroenteritis (13%), irritable bowel syndrome (8%), urinary tract problems (5%), inflammation of the stomach (5%) and constipation (5%). In about 30% of cases, the cause is not determined. About 10% of cases have a more serious cause including gallbladder (gallstones or biliary dyskinesia) or pancreas problems (4%), diverticulitis (3%), appendicitis (2%) and cancer (1%). [2] More common in those who are older, ischemic colitis, [5] mesenteric ischemia, and abdominal aortic aneurysms are other serious causes. [6]

Acute abdomen

Acute abdomen is a condition where there is a sudden onset of severe abdominal pain requiring immediate recognition and management of the underlying cause. [7] The underlying cause may involve infection, inflammation, vascular occlusion or bowel obstruction. [7]

The pain may elicit nausea and vomiting, abdominal distention, fever and signs of shock. [7] A common condition associated with acute abdominal pain is appendicitis. [8] Here is a list of acute abdomen causes:

Surgical causes

Source: [7]

Inflammatory

Mechanical

Vascular

Referred pain

Source: [9]

  • Viscero-visceral referral: happens when one organ with afferent nerves close to another organ is sensitized or inflamed (in this case any of the abdominal viscera) [10]
  • Viscero-somatic referral: any pain in the viscera that causes pain in the muscle, bone, and skin (of the abdomen in case of abdominal pain)
  • Somatic-visceral referral: pain in the skin, muscles, and bone that causes referred pain in the viscera (of the abdomen such as the stomach, kidneys, bladder, etc.)

Medical causes

Source: [7]

Acute pancreatitis.

Sickle cell anemia.

Diabetic ketoacidosis (DKA).

Adrenal crisis.

Pyelonephritis.

Lead poisoning.

Familial Mediterranean fever (FMF).

Gynecological causes

Source: [11]

Pelvic inflammatory disease (PID) and abscess.

Ectopic pregnancy.

Hemorrhagic ovarian cyst.

Adnexal or ovarian torsion.

By system

A more extensive list includes the following:[ citation needed ]

By location

The location of abdominal pain can provide information about what may be causing the pain. The abdomen can be divided into four regions called quadrants. Locations and associated conditions include: [12] [13]

Mechanism

RegionBlood supply [14] Innervation [15] Structures [14]
Foregut Celiac artery T5 - T9 Pharynx

Esophagus

Lower respiratory tract

Stomach

Proximal duodenum

Liver

Biliary tract

Gallbladder

Pancreas

Midgut Superior mesenteric artery T10 – T12Distal duodenum

Cecum

Appendix

Ascending colon

Proximal transverse colon

Hindgut Inferior mesenteric artery L1 – L3Distal transverse colon

Descending colon

Sigmoid colon

Rectum

Fever

Superior anal canal

Abdominal pain can be referred to as visceral pain or peritoneal pain. The contents of the abdomen can be divided into the foregut, midgut, and hindgut. [14] The foregut contains the pharynx, lower respiratory tract, portions of the esophagus, stomach, portions of the duodenum (proximal), liver, biliary tract (including the gallbladder and bile ducts), and the pancreas. [14] The midgut contains portions of the duodenum (distal), cecum, appendix, ascending colon, and first half of the transverse colon. [14] The hindgut contains the distal half of the transverse colon, descending colon, sigmoid colon, rectum, and superior anal canal. [14]

Each subsection of the gut has an associated visceral afferent nerve that transmits sensory information from the viscera to the spinal cord, traveling with the autonomic sympathetic nerves. [16] The visceral sensory information from the gut traveling to the spinal cord, termed the visceral afferent, is non-specific and overlaps with the somatic afferent nerves, which are very specific. [17] Therefore, visceral afferent information traveling to the spinal cord can present in the distribution of the somatic afferent nerve; this is why appendicitis initially presents with T10 periumbilical pain when it first begins and becomes T12 pain as the abdominal wall peritoneum (which is rich with somatic afferent nerves) is involved. [17]

Diagnosis

A thorough patient history and physical examination is used to better understand the underlying cause of abdominal pain.

The process of gathering a history may include: [18]

After gathering a thorough history, one should perform a physical exam in order to identify important physical signs that might clarify the diagnosis, including a cardiovascular exam, lung exam, thorough abdominal exam, and for females, a genitourinary exam. [18]

Additional investigations that can aid diagnosis include: [20]

If diagnosis remains unclear after history, examination, and basic investigations as above, then more advanced investigations may reveal a diagnosis. Such tests include: [20]

Management

The management of abdominal pain depends on many factors, including the etiology of the pain. Some dietary changes that some may participate in are: resting after a meal, chewing food completely and slowly, and avoiding stressful and high excitement situations after a meal. Some at home strategies like these can avoid future abdominal issues, resulting in the need of professional assistance. [21] In the emergency department, a person presenting with abdominal pain may initially require IV fluids due to decreased intake secondary to abdominal pain and possible emesis or vomiting. [22] Treatment for abdominal pain includes analgesia, such as non-opioid (ketorolac) and opioid medications (morphine, fentanyl). [22] Choice of analgesia is dependent on the cause of the pain, as ketorolac can worsen some intra-abdominal processes. [22] Patients presenting to the emergency department with abdominal pain may receive a "GI cocktail" that includes an antacid (examples include omeprazole, ranitidine, magnesium hydroxide, and calcium chloride) and lidocaine. [22] After addressing pain, there may be a role for antimicrobial treatment in some cases of abdominal pain. [22] Butylscopolamine (Buscopan) is used to treat cramping abdominal pain with some success. [23] Surgical management for causes of abdominal pain includes but is not limited to cholecystectomy, appendectomy, and exploratory laparotomy.[ citation needed ]

Emergencies

Below is a brief overview of abdominal pain emergencies.

ConditionPresentationDiagnosisManagement
Appendicitis [24] Abdominal pain, nausea, vomiting, fever

Periumbilical pain, migrates to RLQ

Clinical (history and physical exam)

Abdominal CT

Patient made NPO (nothing by mouth)

IV fluids as needed

General surgery consultation, possible appendectomy

Antibiotics

Pain control

Cholecystitis [24] Abdominal pain (RUQ, radiates epigastric), nausea, vomiting, fever, Murphy's sign Clinical (history and physical exam)

Imaging (RUQ ultrasound)

Labs (leukocytosis, transamintis, hyperbilirubinemia)

Patient made NPO (nothing by mouth)

IV fluids as needed

General surgery consultation, possible cholecystectomy

Antibiotics

Pain, nausea control

Acute pancreatitis [24] Abdominal pain (sharp epigastric, shooting to back), nausea, vomitingClinical (history and physical exam)

Labs (elevated lipase)

Imaging (abdominal CT, ultrasound)

Patient made NPO (nothing by mouth)

IV fluids as needed

Pain, nausea control

Possibly consultation of general surgery or interventional radiology

Bowel obstruction [24] Abdominal pain (diffuse, crampy), bilious emesis, constipation Clinical (history and physical exam)

Imaging (abdominal X-ray, abdominal CT)

Patient made NPO (nothing by mouth)

IV fluids as needed

Nasogastric tube placement

General surgery consultation

Pain control

Upper GI bleed [24] Abdominal pain (epigastric), hematochezia, melena, hematemesis, hypovolemia Clinical (history & physical exam, including digital rectal exam)

Labs (complete blood count, coagulation profile, transaminases, stool guaiac)

Aggressive IV fluid resuscitation

Blood transfusion as needed

Medications: proton pump inhibitor, octreotide

Stable patient: observation

Unstable patient: consultation (general surgery, gastroenterology, interventional radiology)

Lower GI bleed [24] Abdominal pain, hematochezia, melena, hypovolemia Clinical (history and physical exam, including digital rectal exam)

Labs (complete blood count, coagulation profile, transaminases, stool guaiac)

Aggressive IV fluid resuscitation

Blood transfusion as needed

Medications: proton pump inhibitor

Stable patient: observation

Unstable patient: consultation (general surgery, gastroenterology, interventional radiology)

Perforated Viscous [24] Abdominal pain (sudden onset of localized pain), abdominal distension, rigid abdomenClinical (history and physical exam)

Imaging (abdominal X-ray or CT showing free air)

Labs (complete blood count)

Aggressive IV fluid resuscitation

General surgery consultation

Antibiotics

Volvulus [24] Sigmoid colon volvulus: Abdominal pain (>2 days, distention, constipation)

Cecal volvulus: Abdominal pain (acute onset), nausea, vomiting

Clinical (history and physical exam)

Imaging (abdominal X-ray or CT)

Sigmoid: Gastroenterology consultation (flexibile sigmoidoscopy)

Cecal: General surgery consultation (right hemicolectomy)

Ectopic pregnancy [24] Abdominal and pelvic pain, bleeding

If ruptured ectopic pregnancy, the patient may present with peritoneal irritation and hypovolemic shock

Clinical (history and physical exam)

Labs: complete blood count, urine pregnancy test followed with quantitative blood beta-hCG

Imaging: transvaginal ultrasound

If patient is unstable: IV fluid resuscitation, urgent obstetrics and gynecology consultation

If patient is stable: continue diagnostic workup, establish OBGYN follow-up

Abdominal aortic aneurysm [24] Abdominal pain, flank pain, back pain, hypotension, pulsatile abdominal massClinical (history and physical exam)

Imaging: Ultrasound, CT angiography, MRA/magnetic resonance angiography

If patient is unstable: IV fluid resuscitation, urgent surgical consultation

If patient is stable: admit for observation

Aortic dissection [24] Abdominal pain (sudden onset of epigastric or back pain), hypertension, new aortic murmur Clinical (history and physical exam)

Imaging: Chest X-ray (showing widened mediastinum), CT angiography, MRA, transthoracic echocardiogram/TTE, transesophageal echocardiogram/TEE

IV fluid resuscitation

Blood transfusion as needed (obtain type and cross)

Medications: reduce blood pressure (sodium nitroprusside plus beta blocker or calcium channel blocker)

Surgery consultation

Liver injury [24] After trauma (blunt or penetrating), abdominal pain (RUQ), right rib pain, right flank pain, right shoulder painClinical (history and physical exam)

Imaging: FAST examination, CT of abdomen and pelvis

Diagnostic peritoneal aspiration and lavage

Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusion

If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy

Splenic injury [24] After trauma (blunt or penetrating), abdominal pain (LUQ), left rib pain, left flank painClinical (history and physical exam)

Imaging: FAST examination, CT of abdomen and pelvis

Diagnostic peritoneal aspiration and lavage

Resuscitation (advanced trauma life support) with IV fluids (crystalloid) and blood transfusion

If patient is unstable: general or trauma surgery consultation with subsequent exploratory laparotomy and possible splenectomy

If patient is stable: medical management, consultation of interventional radiology for possible arterial embolization

Outlook

One well-known aspect of primary health care is its low prevalence of potentially dangerous abdominal pain causes. Patients with abdominal pain have a higher percentage of unexplained complaints (category "no diagnosis") than patients with other symptoms (such as dyspnea or chest pain). [25] Most people who suffer from stomach pain have a benign issue, like dyspepsia. [26] In general, it is discovered that 20% to 25% of patients with abdominal pain have a serious condition that necessitates admission to an acute care hospital. [27]

Epidemiology

Abdominal pain is the reason about 3% of adults see their family physician. [2] Rates of emergency department (ED) visits in the United States for abdominal pain increased 18% from 2006 through to 2011. This was the largest increase out of 20 common conditions seen in the ED. The rate of ED use for nausea and vomiting also increased 18%. [28]

Special populations

Geriatrics

More time and resources are used on older patients with abdominal pain than on any other patient presentation in the emergency department (ED). [29] Compared to younger patients with the same complaint, their length of stay is 20% longer, they need to be admitted almost half the time, and they need surgery 1/3 of the time. [30]

Age does not reduce the total number of T cells, but it does reduce their functionality. The elderly person's ability to fight infection is weakened as a result. [31] Additionally, they have changed the strength and integrity of their skin and mucous membranes, which are physical barriers to infection. It is well known that older patients experience altered pain perception. [32]

The challenge of obtaining a sufficient history from an elderly patient can be attributed to multiple factors. Reduced memory or hearing could make the issue worse. It is common to encounter stoicism combined with a fear of losing one's independence if a serious condition is discovered. Changes in mental status, whether acute or chronic, are common. [33]

Pregnancy

Unique clinical challenges arise when pregnant women experience abdominal pain. First off, there are many possible causes of abdominal pain during pregnancy. These include intraabdominal diseases that arise incidentally during pregnancy as well as obstetric or gynecologic disorders associated with pregnancy. Secondly, pregnancy modifies the natural history and clinical manifestation of numerous abdominal disorders. Third, pregnancy modifies and limits the diagnostic assessment. For instance, concerns about fetal safety during pregnancy are raised by invasive exams and radiologic testing. Fourth, while receiving therapy during pregnancy, the mother's and the fetus' interests need to be taken into account. [34]

See also

Related Research Articles

<span class="mw-page-title-main">Appendicitis</span> Inflammation of the appendix

Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a ruptured appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Peritonitis</span> Medical condition

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

<span class="mw-page-title-main">Bowel obstruction</span> Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Diverticulitis</span> Digestive disease of the large intestine

Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea, diarrhea or constipation. Fever or blood in the stool suggests a complication. People may experience a single attack, repeated attacks, or ongoing "smouldering" diverticulitis.

<span class="mw-page-title-main">Diverticulosis</span> Condition of the wall of the intestine

Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.

<span class="mw-page-title-main">Fitz-Hugh–Curtis syndrome</span> Medical condition

Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation leading to the formation of adhesions presenting with the clinical syndrome of right upper quadrant (RUQ) pain.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

<span class="mw-page-title-main">Volvulus</span> Twisting of part of the intestine, causing a bowel obstruction

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.

<span class="mw-page-title-main">Diverticular disease</span> Medical condition

Diverticular disease is when problems occur due to diverticulosis, a benign condition defined by the formation of pouches (diverticula) from the weak spots in the wall of the large intestine. This disease spectrum includes diverticulitis, symptomatic uncomplicated diverticular disease (SUDD), and segmental colitis associated with diverticulosis (SCAD). The most common symptoms across the disease spectrum are abdominal pain and bowel habit changes such as diarrhea or constipation. Otherwise, diverticulitis presents with systemic symptoms such as fever and elevated white blood cell count whereas SUDD and SCAD don’t. Treatment ranges from conservative bowel rest to medications such as antibiotics, antispasmodics, acetaminophen, mesalamine, rifaximin, and corticosteroids depending on the specific conditions.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Medical condition

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Abdominal examination</span> Physical examination of abdomen

An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen. Auscultation (listening) of the abdomen with a stethoscope. Palpation of the patient's abdomen. Finally, percussion (tapping) of the patient's abdomen and abdominal organs. Depending on the need to test for specific diseases such as ascites, special tests may be performed as a part of the physical examination. An abdominal examination may be performed because the physician suspects a disease of the organs inside the abdominal cavity (including the liver, spleen, large or small intestines), or simply as a part of a complete physical examination for other conditions. In a complete physical examination, the abdominal exam classically follows the respiratory examination and cardiovascular examination.

<span class="mw-page-title-main">Abdominal distension</span> Physical symptom

Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right. People with this condition often describe it as "feeling bloated". Affected people often experience a sensation of fullness, abdominal pressure, and sometimes nausea, pain, or cramping. In the most extreme cases, upward pressure on the diaphragm and lungs can also cause shortness of breath. Through a variety of causes, bloating is most commonly due to buildup of gas in the stomach, small intestine, or colon. The pressure sensation is often relieved, or at least lessened, by belching or flatulence. Medications that settle gas in the stomach and intestines are also commonly used to treat the discomfort and lessen the abdominal distension.

An abdominal mass is any localized enlargement or swelling in the human abdomen. Depending on its location, the abdominal mass may be caused by an enlarged liver (hepatomegaly), enlarged spleen (splenomegaly), protruding kidney, a pancreatic mass, a retroperitoneal mass, an abdominal aortic aneurysm, or various tumours, such as those caused by abdominal carcinomatosis and omental metastasis. The treatments depend on the cause, and may range from watchful waiting to radical surgery.

<span class="mw-page-title-main">Ischemic colitis</span> Medical condition

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.

An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

<span class="mw-page-title-main">Epiploic appendagitis</span> Medical condition

Epiploic appendagitis (EA) is an uncommon, benign, self-limiting inflammatory process of the epiploic appendices. Other, older terms for the process include appendicitis epiploica and appendagitis, but these terms are used less now in order to avoid confusion with acute appendicitis.

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.

<span class="mw-page-title-main">Intestinal ischemia</span> Restriction of blood flow to the small intestine resulting in injury

Intestinal ischemia is a medical condition in which injury to the large or small intestine occurs due to not enough blood supply. It can come on suddenly, known as acute intestinal ischemia, or gradually, known as chronic intestinal ischemia. The acute form of the disease often presents with sudden severe abdominal pain and is associated with a high risk of death. The chronic form typically presents more gradually with abdominal pain after eating, unintentional weight loss, vomiting, and fear of eating.

<span class="mw-page-title-main">Quadrants and regions of abdomen</span> Anatomical subdivision scheme

The human abdomen is divided into quadrants and regions by anatomists and physicians for the purposes of study, diagnosis, and treatment. The division into four quadrants allows the localisation of pain and tenderness, scars, lumps, and other items of interest, narrowing in on which organs and tissues may be involved. The quadrants are referred to as the left lower quadrant, left upper quadrant, right upper quadrant and right lower quadrant. These terms are not used in comparative anatomy, since most other animals do not stand erect.

References

  1. Patterson JW, Dominique E (14 November 2018). "Acute Abdomenal". StatPearls. PMID   29083722.
  2. 1 2 3 4 5 6 Viniol A, Keunecke C, Biroga T, Stadje R, Dornieden K, Bösner S, et al. (October 2014). "Studies of the symptom abdominal pain—a systematic review and meta-analysis". Family Practice. 31 (5): 517–29. doi: 10.1093/fampra/cmu036 . PMID   24987023.
  3. "differential diagnosis". Merriam-Webster (Medical dictionary). Retrieved 30 December 2014.
  4. 1 2 Sherman R (1990). Abdominal Pain. Butterworths. ISBN   978-0-409-90077-4. PMID   21250252 . Retrieved 28 December 2023.
  5. Hung A, Calderbank T, Samaan MA, Plumb AA, Webster G (1 January 2021). "Ischaemic colitis: practical challenges and evidence-based recommendations for management". Frontline Gastroenterology. 12 (1): 44–52. doi:10.1136/flgastro-2019-101204. ISSN   2041-4137. PMC   7802492 . PMID   33489068.
  6. Spangler R, Van Pham T, Khoujah D, Martinez JP (2014). "Abdominal emergencies in the geriatric patient". International Journal of Emergency Medicine. 7: 43. doi: 10.1186/s12245-014-0043-2 . PMC   4306086 . PMID   25635203.
  7. 1 2 3 4 5 Patterson JW, Kashyap S, Dominique E (2023), "Acute Abdomen", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   29083722 , retrieved 23 September 2023
  8. "Appendicitis". The Lecturio Medical Concept Library. Retrieved 1 July 2021.
  9. Arendt-Nielsen L, Svensson P (March 2001). "Referred Muscle Pain: Basic and Clinical Findings". The Clinical Journal of Pain. 17 (1): 11–19. doi: 10.1097/00002508-200103000-00003 . ISSN   0749-8047. PMID   11289083.
  10. Collantes Celador E, Rudiger J, Tameem A, eds. (2022). Essential Notes in Pain Medicine (1st ed.). United Kingdom: Oxford University Press. doi:10.1093/med/9780198799443.001.0001. ISBN   978-0-19-879944-3.
  11. Burnett LS (April 1988). "Gynecologic causes of the acute abdomen". The Surgical Clinics of North America. 68 (2): 385–398. doi:10.1016/s0039-6109(16)44484-1. ISSN   0039-6109. PMID   3279553.
  12. Masters P (2015). IM Essentials. American College of Physicians. ISBN   978-1-938921-09-4.
  13. LeBlond RF (2004). Diagnostics. US: McGraw-Hill Companies, Inc. ISBN   978-0-07-140923-0.
  14. 1 2 3 4 5 6 Moore KL (2016). "11". The Developing Human Tenth Edition. Philadelphia, PA: Elsevier, Inc. pp. 209–240. ISBN   978-0-323-31338-4.
  15. Hansen JT (2019). "4: Abdomen". Netter's Clinical Anatomy, 4e. Philadelphia, PA: Elsevier. pp. 157–231. ISBN   978-0-323-53188-7.
  16. Drake RL, Vogl AW, Mitchell AW (2015). "4: Abdomen". Gray's Anatomy For Students (Third ed.). Churchill Livingstone Elsevier. pp. 253–420. ISBN   978-0-7020-5131-9.
  17. 1 2 Neumayer L, Dangleben DA, Fraser S, Gefen J, Maa J, Mann BD (2013). "11: Abdominal Wall, Including Hernia". Essentials of General Surgery, 5e. Baltimore, MD: Wolters Kluwer Health.
  18. 1 2 Bickley L (2016). Bates' Guide to Physical Examination & History Taking. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins. ISBN   978-1-4698-9341-9.
  19. ANP-BC KM, ANP-BC LK (6 December 2019). Advanced Health Assessment and Differential Diagnosis: Essentials for Clinical Practice. Springer Publishing Company. p. 250. ISBN   978-0-8261-6255-7.{{cite book}}: CS1 maint: multiple names: authors list (link)
  20. 1 2 Cartwright SL, Knudson MP (April 2008). "Evaluation of acute abdominal pain in adults". American Family Physician. 77 (7): 971–8. PMID   18441863.
  21. "Indigestion: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2 May 2023.
  22. 1 2 3 4 5 Mahadevan SV. Essentials of Family Medicine 6e. p. 149.
  23. Tytgat GN (2007). "Hyoscine butylbromide: a review of its use in the treatment of abdominal cramping and pain". Drugs. 67 (9): 1343–57. doi:10.2165/00003495-200767090-00007. PMID   17547475. S2CID   46971321.
  24. 1 2 3 4 5 6 7 8 9 10 11 12 13 Sherman SC, Cico SJ, Nordquist E, Ross C, Wang E (2016). Atlas of Clinical Emergency Medicine. Wolters Kluwer. ISBN   978-1-4511-8882-0.
  25. A V, C K, T B, R S, K D, S B, et al. (2014). "Studies of the symptom abdominal pain—a systematic review and meta-analysis". Family Practice. Fam Pract. 31 (5): 517–529. doi: 10.1093/fampra/cmu036 . ISSN   1460-2229. PMID   24987023.
  26. Gulacti U, Arslan E, Ooi MW, Tuck J, Mattu A, Dubosh NM, et al. (1 February 2001). "Abdominal Pain and Emergency Department Evaluation". Emergency Medicine Clinics of North America. Elsevier. 19 (1): 123–136. doi:10.1016/S0733-8627(05)70171-1. ISSN   0733-8627. PMID   11214394 . Retrieved 28 December 2023.
  27. Chandramohan R, Pari L, Schrock JW, Lum M, Örnek N, Usta G, et al. (1 May 1991). "Probability of appendicitis before and after observation". Annals of Emergency Medicine. Mosby. 20 (5): 503–507. doi:10.1016/S0196-0644(05)81603-8. ISSN   0196-0644. PMID   2024789 . Retrieved 28 December 2023.
  28. Skiner HG, Blanchard J, Elixhauser A (September 2014). "Trends in Emergency Department Visits, 2006–2011". HCUP Statistical Brief #179. Rockville, MD: Agency for Healthcare Research and Quality.
  29. SA B, LZ R (1987). "Old people in the emergency room: age-related differences in emergency department use and care". Journal of the American Geriatrics Society. J Am Geriatr Soc. 35 (5): 398–404. doi:10.1111/j.1532-5415.1987.tb04660.x. ISSN   0002-8614. PMID   3571788. S2CID   30731138 . Retrieved 28 December 2023.
  30. Rodríguez-Lomba E, Pulido-Pérez A, Ricciardi R, Marcello PW, Kuki I, Nakane S, et al. (1 February 1976). "Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room". The American Journal of Surgery. Elsevier. 131 (2): 219–223. doi:10.1016/0002-9610(76)90101-X. ISSN   0002-9610. PMID   1251963 . Retrieved 28 December 2023.
  31. Weyand CM, Goronzy rJ (2016). "Aging of the Immune System. Mechanisms and Therapeutic Targets". Annals of the American Thoracic Society. American Thoracic Society. 13 (Suppl 5): S422–S428. doi:10.1513/AnnalsATS.201602-095AW. PMC   5291468 . PMID   28005419.
  32. Ed S (1964). "Sensitivity to Pain in Relationship to Age". Journal of the American Geriatrics Society. J Am Geriatr Soc. 12 (11): 1037–1044. doi:10.1111/j.1532-5415.1964.tb00652.x. ISSN   0002-8614. PMID   14217863. S2CID   26336124 . Retrieved 28 December 2023.
  33. Isani MA, Kim ES, Mateu PB, Tormo FB, Thilakarathna K, Xie G, et al. (1 May 2006). "Abdominal Pain in the Elderly". Emergency Medicine Clinics of North America. Elsevier. 24 (2): 371–388. doi:10.1016/j.emc.2006.01.010. ISSN   0733-8627. PMID   16584962 . Retrieved 28 December 2023.
  34. Souza Fd, Ferreira CH, Young RC, Cerit L, Lejong M, Louryan S, et al. (1 March 2003). "Abdominal pain during pregnancy". Gastroenterology Clinics of North America. Elsevier. 32 (1): 1–58. doi:10.1016/S0889-8553(02)00064-X. ISSN   0889-8553. PMID   12635413 . Retrieved 28 December 2023.

Further reading